Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Egle Nursing Home during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia was found with a right hip fracture of unknown origin. The facility's investigation included staff interviews and security footage review but did not include interviews with other residents. The DON acknowledged that interviewing other residents was not considered, which limited the ability to rule out abuse or improper staff handling.
Surveyors identified deficiencies in food storage and expiration date management at the facility. Uncovered pans of cooked food were found in the refrigerator, contrary to the facility's policy, and several canned food items lacked expiration dates. Staff struggled to determine expiration dates, requiring assistance from the food distributor.
The facility failed to review and revise care plans for two residents after assessments. One resident, with severe cognitive impairment and physical limitations, had a care plan that included bed rails, but the plan was not reassessed for effectiveness. Another resident, with severe cognitive impairment and behavioral symptoms, had multiple care plans that were not updated following the most recent MDS assessment. The MDS Coordinator and DON acknowledged these deficiencies.
A resident with a PEG feeding tube was not properly positioned during medication administration and feeding, as the head of bed was elevated only to about 10 degrees instead of the required 45 degrees. The staff member involved admitted to not following the care plan due to nervousness, and the DON confirmed the expectation for proper HOB elevation to prevent aspiration.
A GNA entered a resident's room without knocking or requesting permission, violating the resident's right to dignity and self-determination. The incident was reported to the DON, who noted that the GNA was confused because the door was usually open.
A facility failed to complete a comprehensive MDS assessment for a resident, omitting cognitive and mood evaluations. The MDS Coordinator confirmed the oversight, noting the Social Worker was responsible. The Social Worker acknowledged the error, citing an unrecognized change in the resident's health insurance requirements.
A facility failed to complete a Significant Change in Status MDS assessment within the required 14-day period after a resident experienced a significant decline in condition, including a left tibial plateau fracture. The MDS assessment was completed 24 days after the change was noted, and the MDS coordinator was unaware of the 14-day requirement.
Two residents' MDS assessments were inaccurately coded, leading to deficiencies. One resident's MDS failed to capture the diagnosis for antipsychotic medication use, despite available documentation. Another resident's MDS omitted a BIMS score assessed on the ARD, confirmed by the Social Service Director.
A resident with left hemiparesis due to a stroke did not receive the ordered palm protector to prevent worsening hand contracture. Despite an order for the device to be worn at all times, it was not observed in use, and staff interviews revealed a lack of adherence to the care plan due to oversight and workload issues.
A facility failed to explore alternatives and assess a resident's risk of entrapment before installing bed rails. The resident, with severe cognitive impairment and mobility issues, was unlikely to benefit from the rails. The facility also lacked ongoing evaluation and specific monitoring of the resident's use of bed rails, and did not conduct routine maintenance checks on bed equipment.
The facility failed to ensure timely documentation of physician visit notes for two residents. The EMRs showed that notes were dated after the actual visit dates, indicating a delay in documentation. The DON acknowledged the concerns but did not provide further comments.
A facility staff member failed to wear a gown while providing care to a resident with a PEG feeding tube, despite enhanced barrier precautions requiring both gloves and gowns. The resident needed extensive assistance, and signage indicated the need for these precautions. Interviews confirmed staff were trained and gowns were available, yet the deficiency occurred.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, relying instead on aides to report issues. This deficiency was identified during an observation of a resident with bed rails attached, and the maintenance director confirmed the lack of routine checks. The issue had the potential to affect all residents, and the nursing home administrator acknowledged the concerns.
A facility failed to provide full visual privacy for a resident in a shared room. The privacy curtain only extended to the length of the beds, which was inadequate for a resident using a bedside commode. The DON confirmed that the room's ceiling configuration prevented proper curtain installation.
The facility failed to maintain accurate medical records, including incorrect transcription of antipsychotic medication indications, lack of documentation for a wound evaluation, and missing records of a care plan meeting. These issues involved two residents, one with a Stage III pressure ulcer and another with mental health diagnoses.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident with Alzheimer's disease, dementia, and muscle wasting and weakness. The resident was found sitting in a wheelchair with their right leg in an unnatural position, and a fracture was suspected. The resident was transferred to the hospital, where a right hip fracture was confirmed, requiring surgical intervention. The facility's investigation included interviews with all staff members involved in the resident's care and a review of security footage, which confirmed the resident remained in their room throughout the day. However, there was no evidence that any other residents were interviewed as part of the investigation. During interviews, the DON stated that her process for investigating injuries of unknown origin involved reviewing staff schedules and interviewing staff who had contact with the resident. She acknowledged that she did not consider interviewing other residents, even though this could have provided additional information about the incident. The surveyor noted that without interviewing other residents, the facility could not rule out possible abuse or determine whether staff handling may have contributed to the injury. The DON agreed that interviewing other residents would have been an important step in the investigation.
Deficiencies in Food Storage and Expiration Date Management
Penalty
Summary
The facility staff failed to properly store food items in the kitchen's walk-in refrigerator and did not have a process in place to determine the expiration date of food procured from vendors. During an initial tour of the kitchen, surveyors observed uncovered pans of cooked potatoes and rice pudding in the refrigerator, which were not loosely covered as required by the facility's policy for cooling food products. Staff #7, the Certified Dietary Manager, acknowledged that the pans were uncovered because the food was cooling, but later confirmed that the policy required pans to be loosely covered during cooling. Additionally, the surveyors found several canned food products in the dry storage room that were not labeled with a manufacturer's expiration date or a production date. Staff #7 was unable to determine the expiration dates of these products and had to contact the food distributor for assistance. Although some expiration dates were eventually determined, Staff #7 and Staff #13 were still in the process of verifying the expiration dates for certain products, such as canned apricots and applesauce, at the time of the survey. The Nursing Home Administrator was made aware of these concerns.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for residents after each assessment, as required. This deficiency was observed in the cases of two residents. For the first resident, who had severe cognitive impairment and physical limitations, the care plan included the use of bed rails as enablers. However, the resident was unable to utilize the bed rails due to their dependency on maximum assistance for mobility. Despite this, the care plan was not reassessed to determine the effectiveness of the interventions, such as the need for a bed alarm or assistance with toileting, and the necessity of the bed rails was not reevaluated. In the case of the second resident, who had severe cognitive impairment and exhibited behavioral symptoms, the facility failed to update the care plans following the resident's most recent MDS assessment. The resident's care plans addressed various issues, including behavioral symptoms, cognitive loss, communication, psychotropic drug use, pain management, and pressure ulcers. However, there was no documentation of care plan evaluations or revisions after the assessment, indicating a lack of evaluation of the resident's progress or the effectiveness of current interventions. The MDS Coordinator acknowledged the concerns regarding the failure to evaluate and revise care plans following the MDS assessments. The Director of Nurses was also made aware of these issues. The lack of timely review and revision of care plans for these residents highlights a deficiency in the facility's compliance with regulatory requirements for resident care planning.
Failure to Elevate Head of Bed for PEG Feeding
Penalty
Summary
The facility staff failed to ensure proper elevation of the head of bed (HOB) for a resident during medication administration and infusion of a percutaneous endoscopic gastrostomy (PEG) feeding. This deficiency was identified for one resident who was reviewed for tube feeding. The resident had a PEG feeding tube due to difficulty swallowing, as documented in their care plan. The care plan, initiated in December 2020, included an intervention to keep the HOB elevated at 45 degrees at all times. An attending provider's order from April 2023 also specified that the HOB should be elevated 45 degrees every shift. During an observation in May 2024, the resident was found lying on their back with the HOB elevated to only about a 10-degree angle while a staff member administered medications and resumed PEG feeding. The staff member confirmed that the HOB was not elevated to the required 45 degrees and admitted to elevating it only to about 15 degrees due to nervousness. The Director of Nursing stated that the expectation was for nurses to follow the provider's order to reduce the risk of aspiration, and acknowledged that the staff member had reported the failure to elevate the HOB correctly.
Failure to Respect Resident's Privacy
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not treating them with respect and dignity. This deficiency was identified when a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking or requesting permission. The incident occurred during an interview with the resident, whose room door was closed at the time. The Director of Nurses (DON) was informed of the incident and acknowledged that the GNA had reported being thrown off by the door being closed, as it was usually kept open.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident, specifically omitting the assessment of cognitive patterns and mood. This deficiency was identified during a review of the resident's medical record, which showed that the annual assessment with an Assessment Reference Date (ARD) was not fully completed. The MDS is a federally mandated tool used to ensure that each resident's individual needs are identified and addressed through a standardized assessment process. During an interview, the MDS Coordinator confirmed that the cognitive and mood assessments for the resident had not been completed, attributing the responsibility to the Social Worker. The Social Worker acknowledged the oversight, explaining that a recent change in the resident's health insurance provider, which required completion of these assessments, had not been realized at the time of the assessment.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day period following a significant decline in a resident's condition. This deficiency was identified during a recertification survey for one resident. The resident, who was admitted to the facility in June 2019, experienced a significant change in condition when they complained of left knee pain and swelling on February 13, 2024. An X-ray was ordered, and it was later determined that the resident had a left tibial plateau fracture on February 15, 2024. Despite the significant change in the resident's condition being identified on February 13, 2024, the Significant Change in Status MDS assessment was not completed until March 7, 2024, which was 24 days after the change was noted. The MDS coordinator, during an interview, acknowledged that she was unaware of the requirement to complete the assessment within 14 days of determining a significant change in a resident's condition. This oversight led to the facility's failure to comply with the federally mandated timeline for MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For Resident #64, the MDS assessment did not capture the diagnosis of delusions and hallucinations, which was the indication for the use of an antipsychotic medication. Although a physician's order report signed by an attending provider documented these diagnoses, the MDS coordinator forgot to record them in the MDS assessment. This oversight occurred despite the availability of the necessary documentation prior to the completion of the MDS. For Resident #35, the MDS assessment did not include the Brief Interview for Mental Status (BIMS) score, which was assessed on the same date as the Assessment Reference Date (ARD). The BIMS score of 15/15 was documented in a social service progress note, but it was not captured in the MDS assessment submitted four days later. The omission was confirmed by the Social Service Director, indicating a failure to include all relevant assessment information available during the lookback period.
Failure to Provide Ordered ROM Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to prevent further decline. Resident #43, who was admitted with left hemiparesis due to a stroke, required extensive assistance for self-care and had functional limitations in both upper and lower extremities. An order was in place for the resident to wear a left upper extremity palm protector at all times, except during bathing and hand hygiene, to prevent worsening of hand contracture. However, during an observation, the resident was found without the palm protector, and staff interviews revealed that the device was not consistently used as required. Staff interviews indicated a lack of adherence to the care plan, with a licensed practical nurse unaware of the palm protector's location and a geriatric nurse aide admitting to not checking for the device due to being too busy. The occupational therapy team confirmed the importance of the palm protector in preventing contracture worsening, yet it was not observed in use. This deficiency highlights a failure in the facility's responsibility to provide ordered treatments and services to maintain the resident's range of motion.
Failure to Assess and Monitor Bed Rail Use
Penalty
Summary
The facility failed to identify and use appropriate alternatives before installing bed rails for a resident, and did not assess the resident's risk of injury or entrapment prior to their use. The resident in question had severe cognitive impairment, dementia, hemiplegia, and hand contractures, and was dependent on assistance for all activities of daily living and mobility. Despite these conditions, the facility did not document any exploration of alternatives to bed rails or assess the risks of entrapment before installation. The resident's medical record included a physician's order for bed rails and a signed informed consent form from the resident's representative, acknowledging the risks and benefits of bed rail use. However, the facility did not provide evidence of ongoing evaluation to ensure the bed rails met the resident's needs or that specific monitoring and supervision were provided during their use. The physical therapist confirmed that the resident was unlikely to benefit from the bed rails due to their dependency and inability to grasp the rails. Additionally, the facility lacked a regular maintenance program to inspect bed frames, mattresses, and bed rails, relying instead on reports of issues to address problems. This lack of routine maintenance was acknowledged by the Maintenance Director and discussed with the Nursing Home Administrator, who recognized the concerns raised by the surveyors.
Failure to Document Physician Visit Notes Timely
Penalty
Summary
The facility staff failed to ensure that physician progress notes were written, signed, and dated at each required visit for two residents. For one resident, the electronic medical record (EMR) and paper medical record showed discrepancies in the dates of the physician's visit notes. The notes were dated after the actual visit dates, indicating a delay in documentation. The Director of Nurses (DON) was informed of these concerns and acknowledged them, believing that the physician dictated the notes on the day of the visit. Similarly, for another resident, the EMR revealed that the physician's visit notes were not documented on the day of the visit. The notes were dated several days after the actual visit dates. The DON was made aware of these issues and acknowledged the concerns but did not provide further comments. This deficiency was identified during a review of residents for unnecessary medications.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols by not wearing the required personal protective equipment (PPE) when providing direct care to a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. Specifically, during an observation, a geriatric nurse aide was seen giving a bed bath to the resident while only wearing gloves, neglecting to wear a gown as mandated by the enhanced barrier precautions. These precautions are essential for reducing infection transmission during high-contact care activities for residents with medical devices such as feeding tubes. The resident in question required extensive assistance for all self-care needs and was on enhanced barrier precautions, as indicated by signage on the resident's door. Despite the availability of gowns in the resident's room and staff training on these precautions, the nurse aide did not comply with the requirement to wear a gown. Interviews with the staff, including the director of nursing, confirmed that all staff were expected to follow these precautions, yet the deficiency occurred, highlighting a lapse in adherence to infection control protocols.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is a crucial part of their maintenance program to prevent potential entrapment risks. This deficiency was identified during an observation of a resident lying in bed with bilateral bed rails attached. The maintenance director confirmed that no routine maintenance checks were performed on the beds or bed rails, and the facility relied on aides to report any issues to maintenance for further inspection. The deficiency was evident for one resident reviewed for accidents, but it had the potential to affect all residents in the facility. The maintenance director stated that the facility's protocol involved aides assessing the beds and notifying maintenance if there were any problems. However, there was no structured routine maintenance program in place to ensure the equipment was inspected and maintained according to the manufacturer's recommendations and requirements. The nursing home administrator acknowledged the concerns when they were discussed.
Failure to Provide Full Visual Privacy in Shared Room
Penalty
Summary
The facility failed to provide full visual privacy for a resident residing in a non-private room. This deficiency was identified during a recertification survey for a newly admitted resident who occupied a bed in a shared room. The privacy curtain between the two beds only extended to the length of the beds, failing to provide complete visual privacy. The resident used a bedside commode in the room for bowel and bladder elimination, which further necessitated the need for adequate privacy. The Director of Nursing confirmed the observation and noted that the room's ceiling configuration prevented the installation of a track for suspended curtains, unlike other rooms in the facility.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for its residents, as evidenced by several deficiencies. For one resident, the facility did not accurately transcribe the indication for the use of the antipsychotic medication Seroquel. The medication was prescribed for dementia with psychosis and specific behaviors, but the psychiatric progress note indicated the primary diagnoses as adjustment disorder with anxiety and depressed mood, generalized anxiety disorder, and delusional disorder, with Seroquel continued for delusional disorder. This discrepancy was confirmed by the Director of Nurses during the survey. Additionally, the facility did not document a wound evaluation for the same resident who had a Stage III pressure ulcer on the left ankle. Although the wound was assessed during a dressing change, the evaluation and measurements were not recorded in the electronic health record. Furthermore, another resident's medical record lacked documentation of a care plan meeting following a Minimum Data Set assessment. The Social Service Director and Director of Nursing could not provide evidence of the meeting in the medical record, although an email indicated it occurred.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lonaconing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moran Nursing And Rehabilitation Center | 5.8 mi | — | 4 | 0 |
| Frostburg Rehab Center | 6.8 mi | — | 14 | 0 |
| Mountain City Rehab Center | 7.2 mi | — | 33 | 0 |
| Keyser Healthcare Center | 9.3 mi | — | 19 | 1 |
| Complete Care At Dawnview Llc | 11.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.